Oplinc

The New E-Prescribing Incentive Program

What is E-prescribing?
E-prescribing enables physicians to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care, an element that the Centers for Medicare and Medicaid Services (CMS) says is integral to improving the quality of patient care.

E-prescribing technology includes on-line computerized tools to create and sign prescriptions, perform automated drug safety checks, identify formulary and prescription drug benefits and to help monitor patient medication adherence.

Title 1 of the Medicare Modernization Act of 2003 (MMA) requires drug plans participating in the prescription drug benefit (Part D) to support and comply with electronic prescribing standards. And while E-prescribing is optional for physicians and pharmacies those who choose to E-prescribe covered Part D drugs to enrolled Part D beneficiaries must comply with the E-prescribing standards.

What are the benefits of E-prescribing?
CMS says that E-prescribing can help prevent medication errors by electronically checking dosage, interactions with other medications and therapeutic duplication at the time of prescribing. CMS also believes that E prescribing can improve the quality of care, efficiency, and reduce costs by—

  • Actively promoting appropriate drug usage, such as following a medication regimen for a specific condition.
  • Providing information about formulary-based drug coverage, including formulary alternatives and co-pay information.
  • Speeding up the process of renewing medications by reducing the number of phone calls.
  •  Providing instant connectivity between the health care provider, the pharmacy, health plans/PBMs, and other entities, improving the speed and accuracy of prescription dispensing, pharmacy callbacks, renewal requests, eligibility checks, and medication history.

Furthermore, CMS says E-prescribing will create efficiencies in the administration of the Part D drug benefit, by facilitating patient eligibility checks, promoting generic drugs and appropriate use, and creating timely interface with formularies. E-prescribing will also improve patient safety by preventing medication errors resulting from illegible handwriting on paper prescriptions.

Where can I read more about E-prescribing?
On November 7, 2005, the Medicare Program; E-prescribing and the Prescription Drug Program; Final Rule was published in the Federal Register. The foundation standards included in this rule applied to all electronic prescribing done under Part D of the MMA. CMS implemented pilot projects to test additional standards in 2006 and as a result of these pilot projects additional standards were published in the Medicare Program; Proposed Standards for E-prescribing Under Medicare Part D; Proposed Rule on November 16, 2007.

On April 7, 2008 the Medicare Program; Standards for E-prescribing Under Medicare Part D and Identification of Backward Compatible Version of Adopted Standard for E-prescribing and the Medicare Prescriptions Drug Program (Version 8.1); Final Rule was published in the Federal Register. The final rule adopts uniform standards for formulary and benefit transactions, medications history transactions, and fill status notifications and provides the following three electronic tools for use in E-prescribing:

  • Formulary and benefit transactions: gives prescribers information about which drugs are covered by a Medicare beneficiary's prescription drug benefit plan.
  • Medication history transactions: provides prescribers with information about medications a beneficiary is already taking, including those prescribed by other providers, to help reduce the number of adverse drug events.
  • Fill Status notifications: allows prescribers to receive an electronic notice from the pharmacy telling them that a patient's prescription has been picked up, not picked up, or has been partially filled, to help monitor medication adherence in patients with chronic conditions.

In a July 21, 2008 Press Release CMS announced their latest effort to encourage physician adoption of E-prescribing by offering incentive payments to physicians and other eligible professionals who use the technology saying that E-prescribing is more efficient and convenient for consumers, improves the quality of care, lowers administrative costs and its widespread use would eliminate thousands of medication errors every year.

In the July press release CMS cites the July 2006 Institute of Medicine (IOM) report, Preventing Medical Errors which said that more than 1.5 million Americans are injured each year by drug errors many of which can be prevented through use of E-prescribing. The Department of Health and Human Services says they expect the use of the technology to save the program as much as $156 million over five years through avoided adverse drug events.

How will physicians be impacted?

How will physicians be impacted?
Section 132 of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (H.R. 6331) authorizes CMS to pay an incentive bonus to physicians for successful E-prescribing beginning in 2009 and continuing through 2013. 

For four years beginning in 2009 Medicare will provide incentive payments to eligible professionals who are deemed a successful electronic prescriber. MIPPA of 2008 identifies successful electronic prescribers as those who either report applicable electronic prescribing measures established under the Physician Quality Reporting Initiative (PQRI) or who electronically submit prescriptions under Medicare Part D at a sufficient level as determined by CMS.
Beginning in 2014, bonuses for e-prescribing will be phased out and physicians who haven't adopted E-prescribing will be penalized in the form of reduced Medicare payments. Physicians who have a legitimate reason for not complying may be granted an exception.
Eligible professionals who are successful E-prescribers will receive the following incentive payments:

For 2009 – 2%
For 2010 – 2%
For 2011 – 1%
For 2012 – 1%
For 2013 – 0.5%

Eligible professionals who are not successful E-prescribers face the following reductions in Medicare reimbursement:

For 2012 – 1%
For 2013 – 1.5%
For 2014 & each successive year – 2%

On October 6-7th  in Boston, Massachusetts, CMS held a conference to educate physicians and other stakeholders on the new E-prescribing incentive program. The Medical Group Management Association (MGMA) a proponent of E-prescribing was a cosponsor of the conference. CMS defined the goals of the E-prescribing conference to include:

  • Equip healthcare professionals and other stakeholders with the knowledge and the tools to integrate E-prescribing into their business model;
  • Educate healthcare professionals about the structure and implementation of the incentive payment structure with respect to E-prescribing and PQRI;
  • Generate discussion about the use of E-prescribing and other e-health initiatives to increase patient compliance and overall health outcomes;
  • Identify and promote opportunities to overcome barriers to adoption of this new technology; and
  • Address constituent concerns about privacy, security and risk management with respect to implementation of the E-prescribing incentive payment program.

What if state laws are in conflict with E-prescribing?
CMS reports that they have identified several categories of State laws that are preempted, in whole or in part, upon the effective date of the final rule, January 1, 2006. The following categories of State laws are unenforceable when they apply to covered Part D drugs that are electronically prescribed for Part D eligible individuals and restrict Medicare’s ability to carry out the e-prescribing program:

  • State laws that expressly prohibit electronic prescribing.
  • State laws that prohibit the transmission of electronic prescriptions through intermediaries, such as networks and switches or PBMs, or that prohibit access to such prescriptions by plans or their agents or other duly authorized third parties.
  • State laws that require certain language to be used, such as dispense as written, to indicate whether generic drugs may or may not be substituted in so far as such language is not consistent with the adopted standards.
  • State laws that require handwritten signatures or other handwriting on prescriptions.

CMS Exempts Physicians from DMEPOS Accreditation Requirement for now…

As reported in Volume 4, Issue 2 of the Oplinc Best Practices Review newsletter the Medicare Modernization Act (MMA) of 2003 established the DMEPOS Competitive Bidding Program and section 302(a) (1) of the MMA requires the Secretary to establish and implement quality standards for suppliers of certain items, including consumer service standards, to be applied by recognized independent accreditation organizations.

While physicians and treating practitioners were exempted from having to participate in the competitive bidding program when they provided certain DMEPOS to their own patients they were not exempt from the accreditation requirements.

Physicians and physician organizations have been advocating the physician exemption to the accreditation requirement as the process is time-consuming, expensive and current accreditation requirements are largely impractical for the very small number of items they dispense to their patients.  

Physicians have obtained at least temporary relief from this regulatory burden as Section 154 DELAY IN AND REFORM OF MEDICARE DMEPOS COMPETITIVE ACQUISITION PROGRAM subsection F APPLICATION OF ACCREDITATION REQUIREMENT of the MIPPA contains language that allows CMS to exempt physicians from the DMEPOS accreditation requirement.

This exemption was confirmed by CMS during the September 3, 2008 Special Open Door Forum (ODF) to provide guidance to DMEPOS provider. However, CMS retains the right to establish accreditation standards for physicians in the future…

If you missed this Special Forum an audio recording will be posted to the Special Open Door Forum website at http://www.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp and will be accessible for downloading beginning September 10, 2008.

UnitedHealthcare’s Accreditation Requirement Delayed
On August 20, 2008 UnitedHealthcare published an update on their Web site announcing their decision to delay accreditation requirements for physicians and outpatient imaging sites that bill on a 1500 Health Insurance Claim Form or its electronic equivalent. These providers are required to apply to be accredited before being reimbursed for computed tomography, magnetic resonance imaging, positron emission tomography, nuclear medicine, nuclear cardiology, and echocardiography procedures.

Originally the accreditation requirement was to be effective in the third quarter 2008, but in their announcement UnitedHealthcare says the new requirement will not take effect until the fourth quarter of 2009.

Although the program has been delayed UnitedHealthcare advises providers not to delay in taking the necessary steps to become accredited.

UnitedHealthcare identifies diagnostic imaging accreditation programs as a key initiative to advance the quality and safety of imaging studies and emphasizes the need for consumers to receive services from facilities whose equipment, technologists and physicians are in compliance with established accreditation performance standards.

UnitedHealthcare identified the following key factors in their decision for delaying the program stating:

The recent implementation of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires providers of advanced imaging services to be accredited by Jan. 1, 2012. Effective this date, accreditation will become a mandatory requirement in order to receive payment for the technical component of imaging services. We believe it will be beneficial to our network providers to more closely align our reimbursement adjustment timeline with MIPPA.

While the growth in the number of accredited practices is impressive, we have also received feedback that some communities may not have a sufficient number of accredited facilities to meet patient and physician needs.

UnitedHealthcare recognizes the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC) standards.  Specific accreditation guidelines and standards are available on the ACR and IAC Web sites:

American College of Radiology (ACR)
Acr.org
800.770.0145 

Intersocietal Accreditation Commission (IAC)
Intersocietal.org
800. 838.2110

UnitedHealthcare provides the following chart containing the CPT codes that are included in the UnitedHealthcare Imaging Accreditation Program:

CPT Description
CT
70450 CT, head or brain; without contrast material
70460 CT Head/brain w/ contrast
70470 CT Head/brain w/o & w/contrast
70480 CT, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material
70481 CT orbit w/contrast
70482 CT orbit w/o & w/contrast
70486 CT, maxillofacial area; without contrast material
70487 CT Maxllfcl w/ contrast
70488 CT Maxllfcl w/o & w/contrast
70490 CT, soft tissue neck; without contrast material
70491 CT Soft tissue neck w/contrast
70492 CT Soft tissue neck w/o & w/ contrast
70496 CT Angiography, head, with contrast material(s), including noncontrast images, if performed, and image post processing
70498 CT Angiography, neck, with contrast material(s), including noncontrast images, if performed, and image post processing
71250 CT, thorax; without contrast material
71260 CT Thorax w/ contrast
71270 CT Thorax w/o & w/ contrast
71275 CT Angiography, chest (noncoronary), followed by with contrast material(s), including noncontrast images, if performed, and image post processing
72125 CT, cervical spine; without contrast material
72126 CT C Spine w/ contrast
72127 CT C Spine w/o & w/contrast
72128 CT, thoracic spine; without contrast material
72129 CT T Spine w/ contrast
72130 CT T Spine w/o & w/contrast
72131 CT, lumbar spine; without contrast material
72132 CT L Spine w/ contrast
72133 CT L Spine w/o & w/contrast
72191 CT Angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image post processing
72192 CT, pelvis; without contrast material
72193 CT Pelvis w/contrast
72194 CT Pelvis w/o & w/contrast
72292 CT Guidance
73200 CT, upper extremity; without contrast material
73201 CT Upper extremity w/contrast
73202 CT Upper extremity w/o & w/ contrast
73206 CT Angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image post processing
73700 CT, lower extremity; without contrast material
73701 CT Lower extremity w/contrast
73702 CT Lower extremity w/o & w/ contrast
73706 CT Angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image post processing
74150 CT, abdomen; without contrast material
74160 CT Abdomen w/contrast
74170 CT Abdomen w/o & w/contrast
74175 CT Angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image post processing
76380 CT Limited or localized follow-up study
76497 Unlisted CT Procedure
77011 CT guidance for stereotactic localization
77012 CT guidance for needle placement, radiological supervision and interpretation
0145T CT, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; cardiac structure and morphology
0146T CT, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
0148T CT, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
0150T CT, heart, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post processing; cardiac structure and morphology in congenital heart disease
MR
70336 MR Imaging Temporomandibular Joint
70540 MRI Face, orbit, neck w/o contrast
70542 MRI Face, orbit, neck with contrast
70543 MRI Face, orbit, neck w/& w/o contrast
70544 MRA Head w/o contrast
70545 MRA Head w/ contrast
70546 MRA Head w/& w/o contrast
70547 MRA Neck w/o contrast
70548 MRA Neck w/ contrast
70549 MRA Neck w/& w/o contrast
70551 MRI Head w/o contrast
70552 MRI Head w/contrast
70553 MRI Head w/& w/o contrast
71550 MRI Chest w/o contrast
71551 MRI Chest w contrast
71552 MRI Chest w & w/o contrast
71555 MRA Chest (exc myocardium) w/or w/o contrast
72141 MRI Cervical spine w/o contrast
72142 MRI Cervical spine w/contrast
72146 MRI Thoracic spine w/o contrast
72147 MRI Thoracic spine w/contrast
72148 MRI Lumbar spine w/o contrast
72149 MRI Lumbar spine w/contrast
72156 MRI C Spine w/& w/o contrast
72157 MRI T Spine w/& w/o contrast
72158 MRI L Spine w/& w/o contrast
72159 MRA Spinal canal w/or w/o contrast
72195 MRI Pelvis w/o contrast
72196 MRI Pelvis w/ contrast
72197 MRI Pelvis w/& w/o contrast
72198 MRI Pelvis w or w/o contrast
73218 MRI Upper extremity other than joint w/o contrast
73219 MRI Upper extremity other than joint w contrast
73220 MRI Upper extremity other than joint w/contrast & w/o
73221 MRI Upper extremity joint w/o contrast
73222 MRI Upper extremity joint w/contrast
73223 MRI Upper extremity joint w/& w/o contrast
73225 MRI Upper extremity, with or w/o contrast
73718 MRI Lower extremity other than joint w/o contrast
73719 MRI Lower extremity joint w/contrast
73720 MRI Lower extremity other than joint w/contrast & w/o
73721 MRI Lower extremity joint w/o contrast
73722 MRI Lower extremity joint w/contrast
73723 MRI Lower extremity joint w/& w/o contrast
73725 MRA Lower extremity w/or w/o contrast
74181 MRI Abdomen w/o contrast
74182 MRI Abdomen w/contrast
74183 MRI Abdomen w/& w/o contrast
74185 MRA Abdomen w/or w/o contrast
75557 Cardiac magnetic resonance imaging for morphology and function without contrast material
75558 Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification
75559 Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging
75560 Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification and stress
75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences
75562 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification
75563 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging
75564 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification and stress
75635 CT angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image post processing
76390 MRI Spectroscopy
76498 Unlisted MRI Procedure
77021 MRI Guidance for needle placement; Rad supervision & interpretation
77022 Magnetic resonance guidance for, and monitoring of parenchymal tissue ablation
77058 MRI Breast w/and/or w/o contrast unilateral
77059 MRI Breast w/and/or w/o contrast Bilateral
77084 MRI Imaging Bone Marrow Blood Supply
  Nuclear Medicine
78003 Thyroid suppress or stimulation
78006 Thyroid uptake and scan
78007 Thyroid, image, multiple uptakes
78010 Thyroid scan only
78011 Thyroid imaging with flow
78015 Thyroid met imaging
78016 Thyroid met imaging with additional studies
78018 Thyroid scan whole body
78020 Thyroid carcinoma metastases uptake
78070 Parathyroid nuclear imaging
78075 Adrenal nuclear imaging
78099 Unlisted endocrine procedure, diagnostic nuclear medicine
78102 Bone marrow imaging, limited
78103 Bone marrow imaging, multiple
78104 Bone marrow imaging, whole body
78185 Spleen imaging w & w/o vascular flow
78195 Lymph system imaging
78199 Unlisted hematopoietic diagnostic nuclear medicine
78201 Liver imaging
78202 Liver imaging with flow
78205 Liver imaging spect (3D)
78206 Liver imaging spect w/ vascular flow
78215 Liver & spleen imaging
78216 Liver & spleen imaging with flow
78220 Liver function study
78223 HIDA Scan
78230 Salivary gland imaging
78231 Serial salivary gland
78232 Salivary gland function exam
78258 Esophagus motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux exam
78264 Gastric emptying study
78278 GI Bleeder scan
78282 GI Protein exam
78290 Meckel's diverticulum imaging
78291 Leveen shunt patency exam
78299 Unlisted gastrointestinal procedure
78300 Bone or joint imaging ltd
78305 Bone or joint imaging multiple
78306 Bone scan whole body
78315 Bone scan 3 phase study
78320 Bone joint imaging tomo test
78399 Unlisted musculoskeletal procedure
78414 Non-imaging heart function
78428 Cardiac shunt imaging
78445 Radionuclide venogram non-cardiac
78456 Acute venous thrombosis imaging, peptide
78457 Venous thrombosis imaging unilateral
78458 Venous thrombosis images, bilateral
78459 Myocardial imaging, positron emission tomography (pet) metabolic eval.
78460 Thallium scan rest only
78461 Myocardial perf stress or rest multiple study
78464 Heart image (3-D) single
78465 Myocardial perf w/spect multiple
78466 Myocardial infarction scan
78468 Heart infarct image EF
78469 Heart infarct image 3-D
78472 Gated heart, resting
78473 Cardiac blood pool muga scan
78481 Heart first pass single
78483 Cardiac blood pool imaging-multiple
78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress
78492 Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest or stress
78494 Cardiac blood pool imaging, spect
78496 Cardiac Blood Pool Imaging - Single study @ rest (Use with 78472)
78499 Unlisted cardiovascular nuclear exam
78580 Pulmonary perfusion imaging
78584 Pulmonary perfusion with vent single breath
78585 Pulmonary perfusion w/breath washout, w or w/o single
78586 Pulmonary ventilation imaging
78587 Pulmonary ventilation multi
78588 Pulmonary perfusion w/ventilation
78591 Vent image 1 breath, 1 projection
78593 Vent image 1 projection, gas
78594 Vent image multi projection, gas
78596 Lung differential function
78599 Unlisted respiratory nuclear exam
78600 Brain imaging, less than 4 static views
78601 Brain imaging, less than 4 static views; with vascular flow
78605 Brain imaging, minimum 4 static views
78606 Brain imaging, minimum 4 static views; with vascular flow
78607 Brain imaging, tomographic (SPECT)
78608 Brain imaging, positron emission tomography (PET) metabolic evaluation
78609 Brain imaging, positron emission tomography (PET) metabolic evaluation, perfusion evaluation
78610 Brain flow imaging only
78630 Cisternogram (cerebrospinal fluid flow)
78635 Cerebrospinal ventriculography
78645 CSF Shunt evaluation
78647 Cerebrospinal fluid scan
78650 CSF Leakage detection and localization
78660 Radiopharmaceutical dacryocystography
78699 Unlisted diagnostic nuclear med procedure
78700 Kidney imaging (static)
78701 Kidney imaging w/ vascular flow
78707 Kidney imaging w/study vascular flow & function single
78708 Kidney imaging single study w/pharm. intervention
78709 Kidney imaging- multiple studies w & w/o pharm. intervention
78710 Kidney imaging - tomographic (spect)
78725 Kidney function study - non-imaging radioisotopic
78730 Urinary bladder residual study
78740 Ureteral reflux study
78761 Testicular imaging w/vascular flow
78799 Unlisted genitourinary procedure
78800 Radiopharm localization of tumor or distribution of radiopharm agent(s), limited area
78801 Radiopharm localization of tumor, multiple areas
78802 Radiopharm localization of tumor, whole body, single day imaging
78803 Radiopharm localization of tumor tomographic(spect)
78804 Radiopharm localization of tumor or distribution of radiopharm agent(s); whole body, requiring two or more days imaging
78805 Radiopharm localization of abscess, limited area
78806 Radiopharm localization of abscess, whole body
78807 Radiopharm localization of abscess, tomographic spect
PET
78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)
78812 Positron emission tomography (PET) imaging; skull base to mid-thigh
78813 Positron emission tomography (PET) imaging; whole body
78814 Positron emission tomography (PET) with concurrently acquired CT (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)
78815 Positron emission tomography (PET) with concurrently acquired CT (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh
78816 Positron emission tomography (PET) with concurrently acquired CT (CT) for attenuation correction and anatomical localization imaging; whole body
Echocardiography
93303 Transthoracic Echocardiography for Congenital Cardiac Anomalies; Complete
93304 Transthoracic Echocardiology; Follow-up or Limited Study
93307 Echocardiography, Transthoracic, Real-Time w/Image Documentation w/or w/o M-mode recording; complete
93308 Echocardiography, Transthoracic, Real-Time w/Image Documentation w/or w/o M-mode recording; Follow-up or Limited Study
93312 Echocardiography, Transesophageal, Real-Time with Image Documentation (2D) w/&w/o M-mode recording; including probe placement, image acquisition, interpretation and report
93313 Echocardiography, Transesophageal, Real-Time with Image Documentation (2D) w/&w/o M-mode recording; including probe placement only
93314 Image Acquisition, Interpretation and report only
93315 Transesophageal Echocardiography for Congenital Cardiac Anomalies; including probe placement, image acquisition, interpretation and report
93316 Transesophageal Echocardiography for Congenital Cardiac Anomalies; including probe placement only
93317 Image Acquisition, Interpretation and report only
93318 Echocardiography, transesophageal for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to continuous assessment of cardiac pumping function and to therapeutic measures on an immediate time bases
93320 Doppler Echcontinuous ocardiography, pulsed waved &/or wave with spectral display; complete
93321 Doppler Echocardiography, pulsed waved &/or continuous wave with spectral display; Follow-up or Limited Study
93350 Echocardiography, transthoracic, real-time w/image documentation during rest & cardiovascular stress test using treadmill, bicycle or pharmacologically induced stress, w/interpretation & report.

Source: www.unitedhealthcareonline.com


Published by Rise Marie Cleland. Sponsored by Genentech and hsi

The Medicare Improvements for Patients & Providers Act

The Medicare Improvements for Patients & Providers Act

When Congress overrode the President's veto of H.R. 6331 on July 15, 2008, the  "Medicare Improvements for Patients and Providers Act of 2008” (MIPPA) became law.  MIPPA retroactively rescinds a 10.6% cut in Medicare physician payments that went into effect  July 1, 2008. While the retroactive rescission of physician payments was met with a collective sigh of relief by all, it must be understood that this is just a temporary fix to the physician payment system which remains to be addressed.

MIPPA provides a 0.5% update extension through December 2008 and a 1.1% update for 2009. MIPPA’s 18-month reprieve expires at the end of 2009 and unless Congress acts to prevent it the conversion factor is to be reduced by an estimated 21% on January 1, 2010.

While the temporary fix to physician payments was the cornerstone of MIPPA the bill also contains many other provisions affecting Medicare and Medicaid policy. Below is a brief summary of some of the more significant provisions:

Maintains physician payment rates for 2008 and provides a 1.1% increase for 2009 as described above;
Extends the Physician Quality Reporting Initiative (PQRI) through 2010, increases incentive payments for reporting by 2%, and makes other changes to the program;
Provides incentive payments for electronic prescribing (E-prescribing) for prescribers using qualified E-prescribing systems in 2009-2013. Beginning in 2011 payments will be reduced by 2% for prescribers who fail to e-prescribe beginning in 2011 (see The New E-Prescribing Incentive Program in this newsletter);
Requires certain advanced imaging providers to be accredited by 2012;
Delays and reforms the  durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) Competitive Bidding program terminating contracts awarded under round one and setting the rebid date for 2009 and bidding for round two in 2011. The delay will be financed by cutting fee schedule payments for all items covered by round one bidding by 9.5% nationwide beginning January 1, 2009, followed by a 2% increase (with certain exceptions) in 2014;
Allows for an exemption from the DME accreditation standards for health professionals including physicians until CMS has specific guidelines for health professionals or determines that quality standards apply to these health professionals;
Extends the 1.0 floor to the geographic practice cost index (GPCI) on the physician work relative value unit (RVU) for 18 months;
Requires that the budget neutrality adjustment be applied to the conversion factor and not to the physician work RVUs in 2009;
Repeals the competitive bidding demonstration project for clinical laboratory services and reduces the fee schedule update for clinical lab services by 0.5% in each of the next 5 years;
Extends the use of the cost to charge payment methodology under OPPS for brachytherapy and therapeutic radiopharmaceuticals through January 1, 2010, retroactive to July 1, 2008;
Requires most (PFFS) Medicare plans to establish contracted provider networks for both individual and employer-group products starting in 2010, will no longer allow “deeming” to access providers;
Delays the adoption of Medicaid payment based on average manufacturer price (AMP) for multiple source drugs to retail pharmacies through September 2009 and delays publication of AMP data until October 1, 2009. The National Community Pharmacy Association has stated that the move to payment based on AMP for multi-source drugs would result in reimbursement of 36%, on average, below acquisition cost for every generic prescription.

 

What does the BNA Change Mean?

The Omnibus Budget Reconciliation Act of 1989 requires that increases or decreases in RVUs for a year that result in a change of more than $20 million from what the Medicare expenditures would have been without the changes must be adjusted to ensure budget neutrality.

The 2005 Five Year-Review of Current Procedural Terminology codes resulted in significant increases to the physician work RVUs (RVUs) for many of the most commonly performed Evaluation and Management (E&M) service codes. In order to maintain budget neutrality (BN) CMS applied a -10.1% work RVU adjustment to the 2007 Physician Fee Schedule and an additional -1.7% work RVU adjustment to the 2008 Physician Fee Schedule. This budget neutrality adjustment was applied to the work RVU of all services paid under the Medicare Physician Fee Schedule (labs and drugs were not affected as they are paid under separate fee schedules).

The application of the BN Adjuster to the work RVUs was not well-received. Traditionally CMS has applied the budget neutral adjustment to the conversion factor and the American Medical Association (AMA) and numerous other physician organizations advocated a return to the BN adjustment to the conversion factor. There are several reasons this approach was preferred:

1. When the BN adjustment is applied to work RVUs they disproportionately impact services that involve more physician work while a conversion factor adjustment would consistently impact all services in the physician fee schedule.
2. Some payers utilizing the Medicare fee schedule have also adopted the use of the Budget Neutrality Work Adjuster (BNWA). Because the use of the BNWA reduces the total RVU even if the health plan offers an increase in the conversion factor it may still result in a reimbursement decrease.

The MIPPA contained a provision changing how this Budget Neutrality Adjuster is applied, effective January 1, 2009 the BNA that resulted from the 2005 Five Year - Review will be applied to the conversion factor, rather than the work RVUs.

 


 

 

 

 

 

 

 

 

 

 

 

CONTACT US
Risë Marie Cleland
Rise@Oplinc.com

Oplinc, Inc.
315 W. Mill Plain Blvd.,
Suite 204
Vancouver, WA 98660
360.695.1608 office
360.695.6937 fax
www.Oplinc.com
Rise@Oplinc.com

 

 

 

 

 

 

 

 

 

 

UPCOMING ISSUE
Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com

 

 

 

 

 

 

 

 

 

NEWSLETTER ARCHIVES
Volume 4 Issue 3
Volume 4 Issue 2
Volume 4 Issue 1
Volume 3 Issue 8
Volume 3 Issue 7
Volume 3 Issue 6
Volume 3 Issue 5
Volume 3 Issue 4
Volume 3 Issue 3
Volume 3 Issue 2
Volume 3 Issue 1
Volume 2 Issue 7
Volume 2 Issue 6
Resource Guide Issue 5
Volume 2 Issue 4
Volume 2 Issue 3
Volume 2 Issue 2
Volume 2 Issue 1

 

 

 

 

 

 

 

 

 

 

ABOUT THE EDITOR
Risë Marie Cleland is the founder and President of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc. Ms. Cleland publishes the weekly Oplinc Fax Tracts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

 

 

 

 

 

 

 

 

 

 

IMPORTANT NOTICES
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.hhs.gov.

 

 

 

 

 

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Remove me from this distribution list | Sign up to receive this newsletter